Healthcare Information Systems

Information System
An arrangement of data, processes, people, and technology that interact to collect, process, store, and provide as output the information needed to support an organization.
Administrative Information System
– Contains primarily administrative or financial data
– Used to support the management functions and general operations of the health care organization
Patient Administration Systems (Administrative Apps)
– Admission, discharge, and transfer registration
– Scheduling
– Patient billing or accounts receivable
– Utilization Management
Financial Management Systems (Administrative Apps)
– Accounts Payable
– General Ledger
– Personnel Management
– Materials Management
– Payroll
– Staff Scheduling
Ancillary Information Systems (Clinical Apps)
– Laboratory
– Radiology
– Pharmacy
Use of Health Care Information Systems
Health care environment + State of information technology
HIPAA Definition of Health Care Information
Verbal or written information created or received by a healthcare provider, health plan, public health authority, employer, life insurer, school or university or health care clearing house that relates to the physical or mental health of an individual, or payment for provision of healthcare. (Also called PHI)
Joint Commission Definition of Health Care Information
Defines not only patient-specific, identifiable health care information but also information that is aggregate, knowledge-based, and comparative.
– Divides health care information into four categories:
1) Patient-specific data and information
2) Aggregate data and information
3) Knowledge-based information
4) Comparative data and information
ENIAC
Electronic Numerical Integrator and Computer
UNIVAC
Universal Automatic Computer
Purpose of Patient Records
– Patient Care
– Communication
– Legal Documentation
– Billing and Reimbursement
– Research and Quality Management
Content of Patient Records
– Identification Sheet
– Problem List
– Medication Record
– History and Physical
– Progress Notes
– Consultation
– Imaging and X-Ray reports
– Laboratory Reports
– Consent and Authorization Forms
– Operative Reports
– Pathology Reports
– Discharge Summary
Overview of Inpatient Encounter
– Scheduling
– Preadmission
– Admission / Registration
– Treatment
– Discharge
Physician’s Office Patient Flow
– Check In
– Move to Exam Room
– Examination
– Check Out
– Later Activities
Patient Specific – Administrative
– Data Needed for Reimbursement
~ UB 04
~ CMS 1500
– Other Uniform Data Sets
~ ACDS
~ UHDDS
~ MDS
Uniform Hospital Discharge Data Set (UHDDS) Elements
1. Personal Identification
2. Sex
3. Race
4. Ethinicity
5. Residence
6. Hospital Identification
7-8. Admission and Discharge Dates
9-10. Attending Physician and Operating Physician
11. Diagnosis: Principal diagnosis & other diagnoses
12. Procedure and date
13. Disposition of patient
14. Expected payer
ICD-9-CM
– National Center for Health Sciences
– Inpatient and Outpatient Diagnoses
– Inpatient Procedures
CPT (Current Procdure Terminology)
– American Medical Association
– Outpatient Procedures
Aggregate – Clinical
– Disease and Procdure Indexes
– Specialzed Registers
~ Emergency Room
~ Operating Room
~ Trauma
~ Tumor
Aggregate – Administrative
– Limitless Ad Hoc Reports
– Specific Examples
~ Medicare Cost Reports
~ Health Care Statistics
Census
Discharge
Aggregate – Combined
– Ad Hoc Reports
~ Trend Analysis
~ Statistical Reports
~ Quality Improvement
Comparative
Outcome Measures
– Benchmarking
– Balanced Scorecards
– Clinical Value Compass
Health Care Data Sets
– HEDIS
~ NCQA
– ORYNX
~ JCAHO
– CMS
– Leapfrog Group
Dimensions of Data Quality
Accessibility, Accuracy, Consistency, Comprehensiveness, Currency, Definition, Granularity, Relevancy, Precision, & Timeliness.
Application
The purpose for which the data are collected.
Collection
The processes by which data elements are accumulated.
Warehousing
Processes and systems used to archive data and data journals.
Analysis
The process of translating data into information utilized for an application.
Systematic Data Errors
Caused by a flaw or discrepancy in adherence to standard operating procedures or systems. Can also be casued by unclear data definitions or a failure to comply with the established data collection protocols, such as leaving out required information.
Random Data Errors
Caused by carelessness, lack of attention, or other one-time errors. Poor handwritting that results in an incorrect code would be an example.
Data Error Prevention
– Compose a minimum set of necessary data items
– Define data and data characteristics in a data dictionary
– Develop a data collection protocol
– Create user friendly data entry forms or interface
– Compose data checks
– Create a quality assurance plan
– Train and motivate users
Data Error Detection
– Perform automatic data checks
– Perform data quality audits
– Review data collection protocols and procedures
– Check inter- and intraobserver variability (if appropriate)
– Visually inspect completed forms (online or otherwise)
– Routinely check completeness of data entry
Actions for Data Quality Improvement
– Provide data quality reports to users
– Correct inaccurate data and fill in incomplete data detected
– Control user correction of data errors
– Give feedback of data quality results and recommendations
– Resolve identified causes of data errors
– Implement identified system changes
– Communicate with users
Licensure
-Overseen by the state
– Facilities must have to operate
– Emphasis is on standards for physical plant, safety, etc…
– Minimum standards for patient records
Certification
– Gives authority to participate in Medicare and Medicaid
– Standards were established in the 1970’s
Conditions of Participation (COPs)
Set of minimum standards that must be met in order to participate in federal programs; i.e. Medicare and Medicaid.
Possible Benefits of Accreditation
– Deemed status for CMS programs and some state licensure.
– Required for reimbursement from some payers.
– Validates quality of care.
– May influence liability insurance.
– May enhance managed care contracts.
– Gives competitive edge over non-accredited organizations.
Accreditation
For organizaitons in full compliance.
Provisional Accreditation
For organizations that fail to address all requirements for improvement within 90 days following a survey.
Conditional Accreditation
For organizaitons that are not in substantial compliance with the standards. These organizations must remedy the problem areas and udergo an additional follow-up survey.
Preliminary Denial of Accreditation
For organizations for which there is justification for denying accreditation. This decision is subject to appeal.
Denial of Accreditation
For organizations that fail to meet standards and that have exhausted all appeals.
Preliminary Accreditation
For organizations that demonstrate compliance with selected standards under a special early survey option.
NCQA Five Groups of Published Standards
– Access & Service
– Qualified Providers
– Staying Healthy
– Getting Better
– Living with Illness
NCQA Accreditation Levels
– Excellent
– Commendable
– Accredited
– Provisional
– Denied
AHIMA definition of Legal Health Record (LHR)
The documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization.
AHIMA Four Categories of Patient Data
– Legal Health Record
– Patient-Identifiable Source Data
– Administrative Data
– Derived Data
Protected Health Information (PHI)
– Relates to physical or mental health, provision of or payment for health care.
– Identifies the person.
– Created or received by a covered entity.
– Transmitted or maintained in any form.
HIPAA Privacy Rule Five Major Components
1. Boundaries
2. Security
3. Consumer Control
4. Accountability
5. Public Responsibility
Boundaries
PHI may be disclosed for health purposes only, with very limited excetions.
Security
PHI should not be distributed without patient authorization, unless there is a clear basis for doing so, and the individuals who receive the information must safeguard it.
Consumer Control
Individuals are entitled to access and control their health records and are to be informed of the purposes for which information is being disclosed and used.
Accountability
Entities that improperly handle PHI can be charged under criminal law and punished and are subject to civil recourse as well.
Public Responsibility
Individual interests must not override national priorities in public health, medical research, preventing health care fraud, and law enforcement in general.
Computer Software
Instructions that tell a computer what to do. Software is the entire set of programs, procedures, and routines associated with the operation of a computer system, including the operating system.
Programming Languages
The detailed set of instructions and algorithms used to provide commands and instructions for computers in order to generate useful output.
Generation 1 (1950’s)
Machine Language (1’s & 0’s)
Generation 2 (1960’s)
Assembly Language (Commands: Add, Repeat)
Generation 3 (1960’s – 1980’s)
Procedural Systems (FORTRAN, COBOL)
Generation 4 (1980’s)
User defines problem; computer determines process
Generation 5 (1990-2010)
Artificial Intelligence, fuzzy logic, neutral networks, search engines, queries. Uses visual keys to program
Proprietary Systems
Developed and Sold by private companies for a profit; protected by copyright. Ex: Microsoft Windows, Apple IOS
Open Source Systems
Developed by volunteers and source code (programming) is made available to anyone free of charge. Ex: Linux, Symbian
UNIX Systems
– Developed in 1969 by AT&T
– Used extensively in early Physician Practice systems
– All interface with the user was through the keyboard
– Very simple to learn and use
– Limited capabilities
Graphical User Interface Systems (GUI)
– Originally developed by Xerox; commandeered by Microsoft
– Graphical User Interfaces allow the user to interact more efficiently with the computer information by using graphical rather than by keyboard entries only
– Data entry can be accomplished using: windows, pull-down menus, buttons, scroll bars, icon images, wizards, and of course the mouse
System Software
A series of programs that carry out basic computing functions
– manage user interface, files and memory
– operates peripheals
– allows development of applications without having to include basic computer instructions
Interface Engine
A software program designed to simplify the creation and management of interfaces between applications systems
Patient Management Modules (Administrative Systems)
– Registration (ADT): Admission-Discharge-Transfer
– Automated Registration Documentation Sytem (ARDS)
– Patient Accounting
– Health Information Management (HIM): Medical Records/DRG/Transcription/Record Management
– Master Patient Index/Community Patient Index
– Digital Signature Capture
– Electronic File Management
– Document Scanning
– Quality Improvement
– Contract Management
Financial Accounting Modules (Administrative Systems)
– General Ledger
– Accounts Payable
– Payroll/Personnel
– Human Resources
– Time & Attendance
– Fixed Assets
– Material Management (Purchasing)
– Budgeting
– Executive Information (scorecards, dashboards)
Patient Care Modules (Clinical Systems)
– Point of care systems
– Order Entry/Results Reporting (CPOE)
– Medication Administration Verification (MAR)
– Care Plans
– Patient Acuity
– Resident Assessment Instruments
– Inpatient Rehabilitation Facility
– Core Measures Systems/ CMS Reporting
– Patient Education
Clinical Modules (Clinical Systems)
– Laboratory Information Systems (LIS)
– Anatomic Pathology
– Radiology Information Systems (RIS)
– Imaging Management- Picture Archiving Communications (PACS)
– Physical Therapy
– Cardiopulmonary
– Pharmacy
– Pharmacy Clinical Monitoring
– Operating Room Management
Physician Modules (Clinical Systems)
– Medical Practice EMR
– Charting Software
– Voice Recognition
– Physician PACS Links
Best of Breed (BOB)
Means using a specific software program or package for each specific application or requirement. These are selected based upon their ability to meet the organization’s specific needs better than any other available program. They may be from several vendors and may not be the low-cost package.

While the program does an excellent job in meeting the needs, it may not be able to communicate with other applications the organization is using.

To share information between the applications, the information is either printed out from one package and manually input in to the next or the packages are linked either by the vendor or using a third party “middleware” package or interface system.

Fully Integrated System (FIS)
A software package with a number of integrated modules or applications that cover a range of functions and requirements. Each application may not fully meet the needs of the organzation but workds well with the other applications from the vendor. This is also called a “Single Vendor Solution” or Monolithic Solution”
Stage 0 EMR Adoption Model
All three ancillaries-lab, radiology, pharmacy– not installed.
Stage 1 EMR Adoption Model
Ancillaries all installed.
Stage 2 EMR Adoption Model
Clinical data repository, controlled medical vocabulary, clinical data support system, may have document imaging.
Stage 3 EMR Adoption Model
Clinical documentation, clinical decision support system (error checking) , PACS available outside radiology.
Stage 4 EMR Adoption Model
Computerized provider order entry, clinical decision support system (clinical protocols).
Stage 5 EMR Adoption Model
Closed loop medication administration.
Stege 6 EMR Adoption Model
Physician documentation (structural templates), full clinical decision support system (variance & compliance), full radiology picture archiving and communications system.
Stage 7 EMR Adoption Model
Full electronic medical record, healthcare organization able to contribute continuity of care document as a byproduct of the EMR; data warehousing in use.
Five Barriers to EMR Adoption
1. Cost
2. Support
3. EMR Makeup
4. Interoperability
5. Implementation
*Health Information Technology for Economic and Clinical Health Act (HITECH)
This act is a section of the $787 Billion American Recovery and Reinvestment Act of 2009 (Stimulus Package) which sets aside $19.2 Billion to encourage the adoption of Electronic Heatlh Records by physicians and hospitals.
Meaningul Use
Meaningful Use simply means that a healthcare organization employs its HIT software in a way that provides great value for the patient and other healthcare consumers while ensuring better quality and more efficiency for the provider.
Four Key Principles to Meaningful Use
1. Setting the right EHR goals.
2. Purchasing the right EHR product.
3. The right Implementation of the EHR.
4. The right Use of the EHR by caregivers.
Meaningulf Use Criteria for Providers
Improve the quality, safety, and efficiency of healthcare services
Reduce healthcare disparities
Engage the patients and their families
Improve the coordination of care
Improve population and public health
Ensure the privacy and security of PHI
Criteria and Certification requirements for EHR Software to meet
Securely exchange information among providers and between providers and patients
Standardized formats for reporting
Requirements for internet data exchange
Health Information Exchange
A system that facilitates the electronic movement of health-related information among organizations according to nationally recognized standards.

It consists of the technology, standards, and governance that enables the exchange of data between the disparate information systems of various healthcare providers.

The goal is to facilitate access to and retrieval of clinical data to provide safer, timelier, efficient, effective, equitable, patient-centered care.

Regional Health Information Organizations
The organizations that set up HIEs in a specific region and oversee and coordinate all the HIE activities in that area

Can operate in a city, multicounty, or even a complete state.

eHealth Exchange
Formerly known as the Nationwide Health Information Network (NwHIN)
Is a non-profit, public-private partnership that operationally supports the development of a nationwide system of HIEs that allow comprehensive access to patient health information.
Three Main Categories of Standards
Classification, Vocabulary, and Terminology Standards
Data Interchange Standards
Health Record Content Standards
Ad Hoc Standards of Development Process
A standard is established by the ad hoc method when a group of interested people or organizations agrees on certain specifications, without any formal adoption process.
De Facto Standards of Development Process
Arises when a vendor or other commercial enterprise controls such a large segment of the market that its product becomes the recognized norm.
Government Mandate Standards of Development Process
Standards are also established when the government mandates that the health care industry adopt them.
Consensus
Standards come about when representatives from various interested groups come together to reach a formal agreement on specifications. The process is generally open and involves considering comment and feedback from the industry.
International Organization for Standardization (ISO)
Members are national standards bodies from many countries
ANSI is the US national body member
Oversees the flow of documentation and international approval of standards developed by its member bodies
American National Standards Institute (ANSI)
US member of ISO
Accredits SDOs from a wide range of industries (including health care)
Oversees work of Standards Development Organizations (SDOs)
Does NOT develop standards
Publishes the 10,000+ standards developed by SDOs
Standards Development Organizations (SDO’s)
Must be accredited by ANSI
Develops standards in accordance with ANSI criteria
Can use the label “Approved American National Standard”
270+ ANSI-accredited SDOs representing many industries, including health care
Systemized Nomenclature of Medicine- Clinical Terms (SNOMED CT)
Comprehensive clinical terminology developed specifically to facilitate the electronic storage and retrieval of detailed clinical information
collaboration between the College of American Pathologists (CAP) and the United Kingdom’s National Health Service (NHS).
Logical Observation Identifiers Names and Codes (LOINC)
Developed to facilitate the electronic transmission of laboratory results
Heatlh Level 7 Standards (HL7)
An ANSI-accredited SDO
Develops messaging standards to allow interoperability among health care applications
Digital Imaging and Communications in Medicine (DICOM)
American College of Radiology and the National Electrical Manufacturers Association published the first standard in 1985
Promotes communication of digital image information regardless of device manufacturer
Works with picture archiving and communications systems (PACS)
National Council for Prescription Drug Programs (NCPDP)
ANSI accredited SDO
Developed a standard for the electronic submission of third party drug claims.
Continuity of Care Records (CCR)
designed as a standard healthcare data summary.
Its purpose is to aggregate essential health care data from multiple sources to provide an overall clinical picture of a patient’s current and past health status.
CMS e-Prescribing
Prescriber’s ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy for the point of care
Mandate applies to Medicare Part D transactions
Formulary and benefit transactions
Medication history transactions
Fill status notifications
Problems of Poor Quality Data
– Pt. Care
– Communication among providers & pt’s
– Documentation
– Reimbursement
– Outcomes Assessment
– Research
5 Major Functions negatively affected by poor-quality documentation
– Pt Safety
– Public Safety
– Continuity of Pt Care
– Health Care Economics
– Clinical Research & Outcomes
Medical Record Institute Principles of Health Care Documentation
– Unique Patient Identification within and across systems
– Health care documentation must be
Accurate & consistent
Complete
Timely
Interoperable across systems
Accessible
Auditable
– Confidential and secure authentication and accountability must be provided
Data Accuracy
Data that reflect correct, valid values are accurate. Typographical errors in discharge summaries and misspelled names are examples of inaccurate data.
Data accessiblity
Data that are not available to the decision makers needing them are of no use.
Data comprehensiveness
All of the data required for a particular use must be present and available to the user. Even relevant data may not be useful when they are incomplete.
Data consistency
Use of an abbreviation that has two different meanings. For example, a nurse may use the abbreviation CPR to mean cardio-pulmonary resuscitation at one time and use it to mean computer-based patient record at another time, leading to confusion.
Data Currency
Many types of healthcare data become obsolete after a period of time. A pt’s admitting diagnosis is often not the same as the diagnosis recorded at discharge. If a health care executive needs to report on the diagnoses treated during a particular time frame, which of these two diagnoses should be included?
Data definition
Must be provided so that both current and future data users will understand what the data mean. One way is to use data dictionaries.
Data granularity
Sometimes referred to as data atomicity. That is, individual data elements are “atomic” in the sense that they cannot be further subdivided. For example, a typical pt’s name should generally be stored as three data elements (last name, first name, middle name) not as a single data element.

Related to the purpose for which the data are collected. Although it is possible to subdivide a person’s birth date into spearate fields for the month, the date, and the year, this is usually not desirable.

Values should be defined at the correct level for thier use.

Data relevancy
Data must be relevant to the purpose for which they are collected. We could collect very accurate, timely data about a pt’s color preferences or choice of hairdresser, but is this relevant to the care of the pt.
Data timeliness
A critical dimension in the quality of many types of health care data. Producing accurate results after the pt has been discharged may be or little or no value to the pt’s care.
Microcomputers
Personal computers, network computers, technical workstations, personal digital assistants, information appliances, etc…
Midrange Computers
Network servers, minicomputers, web servers, multiuser systems, etc…
Mainframe Computers
Enterprise systems, superservers, transaction processors, supercomputers, etc…
OSI Seven Layers of Network Communication Protocols
7. Application
6. Presentation
5. Session
4. Transport
3. Network
2. Data Link
1. Physical
Internet Model Network Communication Protocols (TCP/IP)
Application
Transport
Network
Interface
Hub
Device in which data from the network come together.
Bridge
Connects networks at the data link layer; networks with the same protocols
Router
Operates at the network layer; help determine the destination of data.
Gateway
Connects networks with different protocols; operates at or above the transport level.
Switch
May be a gateway or a router; all switches route data to their destinations.
Terminal to Host Distribution Scheme
Dumb terminal interacts with host computer.
File Server Distribution Scheme
Application and database are on one computer; user’s computer gets data files from file server.
Cline/Server Distribution Scheme
Mulitple servers with specialized functions; client runs application & server has data.
Uniform Resource Locator
URL